Non-surgical septal reduction (NSSR) is a promising new therapy for the treatment of classical hypertrophic obstructive cardiomyopathy (HOCM). Patients should have symptoms related to a significant left ventricular outflow tract gradient. The procedure involves the selective injection of absolute alcohol into the hypertrophied basal septum via the epicardial coronary vessels. This results in localized infarction with septal thinning and the other changes that tend to reduce the LVOT gradient. The procedure is well tolerated with low mortality. The principal complication is the development of heart block, which demands pacemaker implantation in around 20% of patients.
Hemodynamic and functional improvement may take some time to become evident and improvement may continue for several months after the procedure. Emerging medium-term follow-up data suggest that the benefits are sustained with no late morbidity. The long-term outcome of the procedure is not known and its value has never been compared to other therapeutic options in randomized controlled trials.

Evidence based strategy of coronary revascularization: The answer to the paradigm shift in the treatment of chronic coronary artery disease

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Yukihiro Kaneko, Werner Mohl

The choice of treatment strategy from medical therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) greatly influences outcome of patients with chronic coronary artery disease. Recent randomized trials and registries provide information as to the judgment of optimal treatment strategy. These studies have shown that best outcome is likely when 1- or 2- vessel disease without proximal left anterior descending artery (LAD) stenosis is treated medically. 2-vessel disease with proximal LAD stenosis or 3-vessel disease without proximal LAD stenosis is treated by PTCA or CABG. 3-vessel disease with proximal LAD stenosis or left main coronary stenosis is treated by CABG. CABG is preferred to PTCA in diabetic patients and patients with decreased left ventricular function. Recent advances in the treatment of coronary artery disease are also reviewed as they influence current treatment strategy.

As many as 20% of referrals for fetal echocardiography is due to fetal arrhythmias. They may occur in 2% of pregnancies. Indication for echocardiographic evaluation of heart rhythm are sustained fetal heart rate below 100 beats per minute, sustained heart rates above 180 beats per minute, unexplained hydrops fetalis, and frequent and repetitive irregular heart beats. Fetuses with either sustained bradycardia or tachycardia deserve expeditious evaluation. The most important fetal bradycardia is a complete atrioventricular block, which can be associated with a structural heart disease or occur as a consequence of maternal collagen vascular disease and/ or lupus associated antibodies. Fetal therapy is difficult and often unsuccessful. The most common serious fetal tachycardia is orthodromic reciprocating atrioventricular tachycardia followed by atrial flutter. These tachycardias can be treated in utero and proposed protocols for drug management are described. A close fetal and maternal monitoring during treatment and a team approach is advised.